Pelvic Organ Prolapse

What is Pelvic Organ Prolapse (POP)?

The pelvic organs, such as the uterus, rectum and bladder, are held in place by muscles, tissue and ligaments. Prolapse happens when one or more of these organs slip down from its normal position and into the vagina, because the supportive tissues have become weak. Most women with pelvic organ prolapse will notice a bulge or feel pressure/heaviness in the vagina. It is not a life threatening condition and does not need to be treated unless the symptoms are bothersome. It is often associated with urinary incontinence.

What are the types of POP?

Descent of the front vaginal wall is called anterior vaginal prolapse. It is also called a cystocele due to descent of the bladder in front of the vagina.

Descent of the back vaginal wall is called posterior vaginal prolapse. It is also called a rectocele or an enterocele due to descent of the bowel behind the vagina.

Descent of the uterus and cervix is called uterine prolapse. If you have had a hysterectomy, it may be called vaginal vault prolapse.

What causes POP?

The pelvic organs are supported by muscles, and strong tissues called ligaments and fascia. Damage to any of these structures can result in descent of the pelvic organs. Although the specific causes of POP are unknown, there are risk factors for developing POP that are related to tissue, nerve or muscle weakness or damage. Previous pregnancies and vaginal births can cause injury to these structures and may be related to the development of POP at any time in the future. Other risk factors include obesity, aging, nerve and connective tissue disorders, and increased abdominal pressure due to heavy lifting or chronic coughing, for example.

How is POP diagnosed?

A careful history and a physical examination will be performed by your doctor. The pelvic exam will identify what type of POP you have. A grade or stage will be assigned to classify how severe the POP is and will be used to monitor progression and response to treatment. If you have urinary symptoms, such as incontinence, other testing may be performed (see info on urinary incontinence). Urodynamic testing may be recommended in order to rule out associated urinary leakage or to try to predict whether it may occur after treatment.

General recommendations for POP include:

  1. Do not strain to void or have bowel movements. Keep stools soft and avoid constipation. Gentle stimulants and stool bulking agents, such as natural fiber, Milk of Magnesia, Metamucil or mineral oil, are recommended.
  2. Empty your bladder completely with each void. You may need to shift positions, stand up and sit down again, lean forward or gently push on your lower abdomen.
  3. Watch for symptoms of urinary tract infections such as urinary urgency or frequency, blood in the urine or burning with voiding. Tell your doctor if you have these symptoms.
  4. Weight loss is a very important aspect of bladder control and POP. Excess weight will cause increased pressure on the pelvic organs. Weight loss, even a little, will significantly improve symptoms, as well as reduce complications of surgery.
  5. Pelvic floor muscle training (Kegel exercises) is a series of short repetitive muscle contractions to strengthen the muscles of the pelvic floor that support the vagina, bladder and urethra. They are particularly helpful for stress incontinence or genital prolapse if done consistently. Biofeedback or vaginal cones are also methods of doing Kegel exercises. For more information, ask your doctor.
  6. Vaginal estrogen cream, pill or ring may be recommended, especially if the vaginal tissue is irritated or thin.

What is a vaginal pessary?

A pessary is a device that is inserted into the vagina to reduce POP and improve symptoms. A pessary needs to be fitted by a healthcare professional and may take some trial and error to find the best size and shape. There is a small one-time fee to purchase the device. After the pessary has been fit, most women do not feel it inside the vagina.

Many women can be taught how to remove, clean and insert it themselves, to make its use more convenient. If this is not possible, appointments can be made with your doctor to clean it approximately every 3 to 6 months. Estrogen or a lubricant cream may be recommended to avoid irritation from the device. A pessary can be used long-term or in the short-term, while awaiting surgery.

What are the surgical options?

Surgical procedures attempt to restore a normal anatomical position to the vagina. These procedures may be done through an incision in the vagina or the abdomen. All surgeries have complications and it is important to understand these beforehand. There are many procedures not mentioned here.

Abdominal colposacropexy - a procedure for vaginal vault prolapse performed through an incision in the abdomen. A synthetic mesh is attached to the vagina and suspended from the backbone (sacrum).

Sacrospinous ligament suspension - a procedure performed through the vagina where stitches are placed from the vagina to a ligament near the backbone (sacrospinous ligament).

Hysterectomy – a procedure to remove the uterus that is performed when the uterus is falling down.

These procedures may be combined with bladder repair surgeries, if necessary or other procedures for POP. Your doctor will discuss the options and type of surgery that is best suited for you.